- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.53 / $3,110.93 / $4,388.35
| Professional | | $154.53 | $3,110.93 | $4,388.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.93 / $2,829.22 / $5,763.67
| Professional | | $257.93 | $2,829.22 | $5,763.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.94 / $2,998.92 / $6,603.53
| Professional | | $246.94 | $2,998.92 | $6,603.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $2,900.08 / $4,983.53
| Professional | | $32.34 | $2,900.08 | $4,983.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.94 / $2,998.92 / $7,229.92
| Professional | | $246.94 | $2,998.92 | $7,229.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,530.09 / $6,272.76 / $9,252.62
| Professional | | $4,530.09 | $6,272.76 | $9,252.62 |